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Patient information: See related handout on shingles, written by the authors of this article. Herpes zoster and progression to AIDS in a cohort of individuals who seroconverted to human immunodeficiency virus. A retrospective study of the clinical presentation and outcome of herpes zoster in a tertiary dermatology outpatient referral clinic. Valaciclovir compared with acyclovir for improved therapy for herpes zoster in immunocompetent adults.
The effects of early corticosteroid therapy on the skin eruption and pain of herpes zoster.
Lidocaine patch: double-blind controlled study of a new treatment method for post-herpetic neuralgia. Herpes zoster infection (shingles) results from the reactivation of varicella zoster virus infection. While varicella virus infection mostly affects the young, shingles and its complications mainly affect older persons.
The initial stage of shingles precedes the active stage with a conundrum of symptoms that last several days or weeks before the shingle rash appears.
The rash develops from maculopapular lesions forming a beltlike pattern on the patient's trunk, but the band of rash may appear anywhere on the body including the eyes. The main symptom associated with postherpetic neuralgia is pain, which persists for a long period beyond the resolution of the shingles rash. The lidocaine 5% patch has been shown to be easy to use, safe, tolerable, and efficacious in the management of PHN pain. Gabapentin prevents allodynia and hyperalgesia associated with PHN pain as well as the associated sleep disorder.
Anticonvulsants have been shown to be equally efficacious; however, drug selection may involve trial and error. This injection allows doctors to diagnose if the pain is originating from the chest or the internal organs. HERPES ZOSTER OPHTHALMICUS COMPLICATIONSnov , incidence and varicella rarely found inwe describe a well. Whereas varicella is generally a disease of childhood, herpes zoster and post-herpetic neuralgia become more common with increasing age. Unlike varicella (chickenpox), herpes zoster is a sporadic disease with an estimated lifetime incidence of 10 to 20 percent. The prodrome generally lasts one to two days but may precede the appearance of skin lesions by up to three weeks.During the prodromal phase, herpes zoster may be misdiagnosed as cardiac disease, pleurisy, a herniated nucleus pulposus or various gastrointestinal or gynecologic disorders. Although the diagnosis of the conditions is generally straightforward, treatment can be frustrating for the patient and physician. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. In excess of 60% of people older than 60 years, especially those with diminished immunity due to diabetes and cancers, are afflicted by herpes zoster. Patients with early signs of shingles complain of headaches, hypersensitivity to light, flulike symptoms without fever, itching, tingling, and burning or pain around the affected area. The features of PHN pain vary from mild to excruciating in severity, can be constant or intermittent, or triggered by trivial stimuli.
Prednisone use in conjunction with acyclovir resulted in the reduction of the pain associated with acute herpes zoster. The application of capsaicin to the skin produces a burning sensation, which triggers the release of substance P, a neuropeptide, from pain fibers. Lidocaine is an amide-type local anesthetic agent that stabilizes neuronal membranes by inhibiting the ionic fluxes required for the initiation and conduction of impulses.
Pharmacologically, this action may potentiate or prolong neuronal activity since reuptake of these biogenic amines is important physiologically in terminating transmitting activity. It binds with high affinity to the alpha2-delta site (an auxiliary subunit of voltage-gated calcium channels) in central nervous system tissues to produce antinociceptive effects.
If there is inadequate response to one anticonvulsant agent, another agent should be tried. Opioid analgesics in combination with acetaminophen or nonsteroidal anti-inflammatory drugs may be useful as a last resort in patients with severe PHN pain unrelieved by other drugs.
Nerve blocks provide periods of dramatic pain relief, which promotes the desensitization of sensory pathways.
The outcome of treatment of shingles is often unsatisfactory, although the antiviral medications reduce the duration of pain during the acute phase but do not prevent PHN complications and pain. More than 50% of the people who live to be 85 years old will develop shingles, and 80% to 85% of PHN complication occurs in patients older than 50 years. I know of crippled walking, ambulation problems with Post-herpetic neuralgia more than a year after the acute infection. It provides great pain relief for rib fracture.This block is also useful for pain associated with herpes zoster and chest wall contusion. Factors that decrease immune function, such as human immunodeficiency virus infection, chemotherapy, malignancies and chronic corticosteroid use, may also increase the risk of developing herpes zoster. The incidence of herpes zoster increases sharply with advancing age, roughly doubling in each decade past the age of 50 years. Antiviral agents may be beneficial as long as new lesions are actively being formed, but they are unlikely to be helpful after lesions have crusted.The effectiveness of antiviral agents in preventing postherpetic neuralgia is more controversial. Pain therapy may include multiple interventions, such as topical medications, over-the-counter analgesics, tricyclic antidepressants, anticonvulsants and a number of nonmedical modalities.
Approaches to management include treatment of the herpes zoster infection and associated pain, prevention of postherpetic neuralgia, and control of the neuropathic pain until the condition resolves. The National Institute of Allergy and Infectious Diseases Collaborative Antiviral Study Group. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. This reactivation and the accompanying inflammation lead to central nervous system dysfunction, which is manifested as debilitating pain. Initially, the host is able to produce varicella zoster virus—specific, cell-mediated immunity during the infection. The affected nerves are usually found on the trunk of the body but may sometimes be distributed on the face, neck, arm, leg, or abdomen. Keratitis occurs in approximately two-thirds of patients with HZO, often causing corneal ulceration.
Patients complain of pain in response to nonnoxious stimuli such as pressure from clothing, bed sheets, or the wind. The second objective is to treat the associated pain in the acute phase and in PHN, and the third objective is to prevent the occurrence of PHN and other complications.
It has been postulated that the mechanism of the steroid effect is due to decrease in the degree of neuritis caused by the active infection, decreasing the resulting damage to affected nerves. The depletion of substance P in the nerve fibers from repeated exposure to capsaicin results in analgesia. In patients with PHN, the lidocaine 5% patch has demonstrated relief of pain and tactile allodynia with a minimal risk of systemic adverse effects or drug—drug interactions.
The side effects to be concerned about, especially in the elderly, include nystagmus, ataxia, skin eruptions, hematological complications, and gingival hyperplasia.
Carbamazepine is chemically unrelated to other anticonvulsants or other drugs used to control PHN pain. Opioid analgesic side effects include nausea, vomiting, constipation, dizziness, headache, and respiratory depression. High-frequency TENS activates delta-opioid receptors both in the spinal cord and supraspinally (in the medulla), while low-frequency TENS activates mu-opioid receptors both in the spinal cord and supraspinally.


In this technique, local anesthetics, steroids, and opioid medications are injected around the affected nerve to relieve pain. Thus, early management of shingles is essential to prevent the many complications, especially the chronic, debilitating, difficult-to-treat PHN pain that often results from the condition. For patients who are terminally ill from cancer ,destruction of these nerves (rhizotomy) using phenol or radiofrequency provide additional relief. Reactivation of latent varicella-zoster virus from dorsal root ganglia is responsible for the classic dermatomal rash and pain that occur with herpes zoster. How the virus enters the sensory dorsal root ganglia and whether it resides in neurons or supporting cells are not completely understood.
Numerous studies evaluating this issue have been conducted, but the results have been variable. Primary treatment modalities include antiviral agents, corticosteroids, tricyclic antidepressants and anticonvulsants. Low levels of immune globulin have been shown to predispose patients to recurring herpes zoster infection. These vesicles become crusted within 7 to 10 days and are shed, leaving scarring and pigmented changes on the skin. Other complications include conjunctivitis, uveitis, episcleritis and scleritis, retinitis, choroiditis, optic neuritis, lid retraction, ptosis, and glaucoma.
To achieve these objectives, antiviral agents, oral corticosteroids, and pain management are utilized. The main disadvantages when acyclovir is administered orally are low bioavailability and the 5-hour dosing frequency. Despite the usefulness of prednisone in managing the associated pain with herpes zoster infection, it has not been shown to decrease or prevent the incidence of PHN.
Capsaicin cream must be applied three to five times daily to achieve substance P depletion from the pain fiber and analgesia.
TCA therapy should be initiated with low doses to improve tolerability and be administered at bedtime. The drawback to using carbamazepine is the serious and sometimes fatal dermatologic reactions, including toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome. Further, high-frequency TENS reduces excitation of central neurons that transmit nociceptive information, reduces release of excitatory neurotransmitters (glutamate), increases the release of inhibitory neurotransmitters (GABA) in the spinal cord, and activates muscarinic receptors centrally to produce analgesia by temporarily blocking the pain gate. This type uses a device that measures muscle tension while the patient practices a relaxation technique such as meditation, progressive muscle relaxation, or visualization.
I believe it is a neurologic condition and that it should be aggressively treated with some kind of physiologic treatments by a neurologist.
Burning pain typically precedes the rash by several days and can persist for several months after the rash resolves. In a recent study,1 patients more than 55 years of age accounted for more than 30 percent of herpes zoster cases despite representing only 8 percent of the study population. Postherpetic neuralgia is very resistant to treatment and results in decreased quality of life. Periodically, endogenous and exogenous boosting of the immunity against varicella results in the virus remaining dormant for decades.
Pain is the primary complaint with active-stage shingles and the symptom for which patients seek medical care. The pain, which is characterized as burning and lancinating, is chronic, intractable, and distressing. Pain therapy may involve the use of multiple agents including topical analgesics, tricyclic antidepressants, anticonvulsants, narcotics, and intervention therapy (TABLE 2). The need for regular application of capsaicin must be emphasized to patients to maintain pain relief. The dose can be titrated every 2 to 4 weeks until maximum tolerated dose to achieve results. Tramadol, a centrally active synthetic opioid analgesic, is a useful alternative because it lacks the abuse potential associated with other opioids.
The cells, virus seeds, virus bulks, and bovine serum used in the manufacturing are all tested to provide assurance that the final product is free of adventitious agents.
With postherpetic neuralgia, a complication of herpes zoster, pain may persist well after resolution of the rash and can be highly debilitating.
In this same study, children less than 14 years old represented only 5 percent of herpes zoster cases.The normal age-related decrease in cell-mediated immunity is thought to account for the increased incidence of varicella-zoster virus reactivation. The reactivated virus travels down the sensory nerve and is the cause for the dermatomal distribution of pain and skin lesions.The pathophysiology of postherpetic neuralgia remains unclear. Eventually, reactivation of the virus occurs as a result of decline in virus-specific, cell-mediated immunity. It can disrupt sleep, mood, work, and activities of daily living, adversely impacting the quality of life and leading to social withdrawal and depression.
The parenteral route is available for patients who are unable to utilize the oral dosing route. Additionally, patients must understand that the pain may initially increase within the first week of initiating the therapy because it initially acts as an irritant by stimulating the nerve endings before desensitizing afferent C-fibers.
Lidocaine-containing patches significantly reduce pain intensity throughout the dosing interval for up to 12 hours. TCAs act slowly and may require up to 3 months before achieving adequate response in patients. The side effects that are associated with anticonvulsants include sedations memory disturbance, electrolyte abnormalities, liver toxicities, and thrombocytopenia.
The CDC Advisory Committee on Immunization Practices recommends routine vaccination of all persons age >60 years with one dose of zoster vaccine.
Patients with disease states that affect cell-mediated immunity, such as human immunodeficiency virus (HIV) infection and certain malignancies, are also at increased risk. Major drawbacks of orally administered acyclovir include its lower bioavailability compared with other agents and its dosing frequency (five times daily). Normal age-related decline and diseases such as malignancies and HIV impact the reduction in cell-mediated immunity and the reactivation of dormant varicella virus.
Occasionally, zoster can cause motor weakness in noncranial nerve distributions, calledzoster paresis. The pain is stipulated to be due to persistent C-fiber nociceptor activity in the nerve cells, although studies have shown chronic neural loss and scarring in nerves affected by herpes zoster injury. It is important to educate patients on the need for thorough hand washing after each application of capsaicin. Lidocaine patches were superior to both no treatment and vehicle patches in averaged category pain relief scores. Combining TCAs with antiviral drugs during herpes zoster infection has been shown to decrease the intensity of PHN pain but does not prevent it.
These side effects can be minimized by initiating therapy with low doses and slowly titrating doses upward over several weeks. Patients can decrease their pain by increasing their body temperature through visualization or guided imagery.
Indeed, patients may have insomnia because of the pain.10 Although any vertebral dermatome may be involved, T5 and T6 are most commonly affected. Intravenously administered acyclovir is generally used only in patients who are severely immunocompromised or who are unable to take medications orally.Valacyclovir, a prodrug of acyclovir, is administered three times daily.
The reactivated virus travels down the sensory nerve, causing pain and skin lesions (FIGURE 1). One specific risk for patients who are immunocompromised is dissemination of the zoster rash.
The weakness develops abruptly within 2 to 3 weeks after onset of the rash and can involve upper or lower extremities.


Another advantage of valacyclovir compared to acyclovir is better bioavailability, producing comparable blood levels to parenteral acyclovir. The main side effects expected from TCA therapy are sedation, dry mouth, postural hypotension, blurred vision, and urinary retention. Zoster vaccination is not indicated to treat acute zoster, to prevent persons with acute zoster from developing PHN, or to treat ongoing PHN.
The antiviral medications are most effective when started within 72 hours after the onset of the rash. Blacks are one fourth as likely as whites to develop this condition.4 Although herpes zoster is not as contagious as the primary varicella infection, persons with reactivated infection can transmit varicella-zoster virus to nonimmune contacts. The most frequently involved cranial nerve dermatome is the ophthalmic division of the trigeminal nerve.
Cutaneous dissemination generally occurs only among immunocompromised patients, occurring in up to 37% of zoster cases in the absence of antiviral treatment.
Valacyclovir appears to be more efficacious in decreasing the severity of pain associated with acute herpes zoster and the duration of the PHN when compared to acyclovir.
No clinically significant systemic adverse effects were noted, including when used long-term or in an elderly population. Before routine administration of zoster vaccine, it is not necessary to ask patients about their history of varicella (chickenpox) or to conduct serologic testing for varicella immunity. The addition of an orally administered corticosteroid can provide modest benefits in reducing the pain of herpes zoster and the incidence of postherpetic neuralgia.
Household transmission rates have been noted to be approximately 15 percent.5About 20 percent of patients with herpes zoster develop postherpetic neuralgia.
The advantages of famciclovir are its dosing schedule (three times daily), its longer intracellular half-life compared with acyclovir and its better bioavailability compared with acyclovir and valacyclovir.The choice of which antiviral agent to use is individualized.
To achieve this response, capsaicin cream must be applied to the affected area three to five times daily.
While cutaneous dissemination is not life-threatening, it is a marker for potential virus seeding of the lungs, liver, gut, and brain and can cause pneumonia, hepatitis, encephalitis, and disseminated intravascular coagulopathy in 10% to 50% of episodes. Rarely, patients will experience acute focal neurologic deficits weeks to months after resolution of the zoster rash, involving the trigeminal distribution contralateral to the initial rash.
Ocular involvement in herpes zoster can lead to rare but serious complications and generally merits referral to an ophthalmologist.
The most established risk factor is age; this complication occurs nearly 15 times more often in patients more than 50 years of age.
Of these patients, approximately one half manifest other neurologic or visceral involvement, and as many as one in seven with viremia may die.The vesicles eventually become hemorrhagic or turbid and crust over within seven to 10 days. Patients must be counseled about the need to apply capsaicin regularly for continued benefit. Famciclovir has the advantage of having longer intracellular half-life compared with acyclovir and a superior biovailability compared to both acyclovir and valacyclovir.
Cardiac conduction impairment or liver toxicity may develop in some patients, especially in elderly patients or those at high risk. As the crusts fall off, patients are generally left with scarring and pigmentary changes.Ocular complications occur in approximately one half of patients with involvement of the ophthalmic division of the trigeminal nerve. The recommended dosages for acyclovir, famciclovir and valacyclovir are provided in Table 1. They also need to be counseled that their pain will likely increase during the first few days to a week after capsaicin therapy is initiated. When antiviral therapy starts within 72 hours of the onset of herpes zoster, acyclovir, valacyclovir, and famciclovir have been shown to significantly shorten the periods of acute pain, virus shedding, rash, and acute and late-onset complications.
Tricyclic antidepressants or anticonvulsants, often given in low dosages, may help to control neuropathic pain.
These complications include mucopurulent conjunctivitis, episcleritis, keratitis and anterior uveitis. Patients should wash their hands thoroughly after applying capsaicin cream in order to prevent inadvertent contact with other areas.Patches containing lidocaine have also been used to treat postherpetic neuralgia. Other rare neurologic complications of herpes zoster include myelitis, aseptic meningitis, and meningoencephalitis.
Both valacyclovir and famciclovir have been shown to lessen the incidence and severity of PHN. Cranial nerve palsies of the third, fourth and sixth cranial nerves may occur, affecting extraocular motility.The most common chronic complication of herpes zoster is postherpetic neuralgia. One study found that compared with no treatment, lidocaine patches reduced pain intensity, with minimal systemic absorption.
The risk for neurologic zoster complications is generally increased in immunocompromised persons. Pain that persists for longer than one to three months after resolution of the rash is generally accepted as the sign of postherpetic neuralgia.11 Affected patients usually report constant burning, lancinating pain that may be radicular in nature. However, these agents are often useful for potentiating the pain-relieving effects of narcotics in patients with severe pain. Even the slightest pressure from clothing, bedsheets or wind may elicit pain.Postherpetic neuralgia is generally a self-limited disease. Because of the addictive properties of narcotics, their chronic use is discouraged except in the rare patient who does not adequately respond to other modalities.TRICYCLIC ANTIDEPRESSANTSTricyclic antidepressants can be effective adjuncts in reducing the neuropathic pain of postherpetic neuralgia. These agents most likely lessen pain by inhibiting the reuptake of serotonin and norepinephrine neurotransmitters.22Tricyclic antidepressants commonly used in the treatment of postherpetic neuralgia include amitriptyline (Elavil), nortriptyline (Pamelor), imipramine (Tofranil) and desipramine (Norpramin).
The dosage is increased every two to four weeks to achieve an effective dose.The tricyclic antidepressants share common side effects, such as sedation, dry mouth, postural hypotension, blurred vision and urinary retention.
Nortriptyline and amitriptyline appear to have equal efficacy; however, nortriptyline tends to produce fewer anticholinergic effects and is therefore better tolerated.
Treatment with tricyclic antidepressants can occasionally lead to cardiac conduction abnormalities or liver toxicity. The potential for these problems should be considered in elderly patients and patients with cardiac or liver disease.Because tricyclic antidepressants do not act quickly, a clinical trial of at least three months is required to judge a patient's response. The onset of pain relief using tricyclic antidepressants may be enhanced by beginning treatment early in the course of herpes zoster infection in conjunction with antiviral medications.20ANTICONVULSANTSPhenytoin (Dilantin), carbamazepine (Tegretol) and gabapentin (Neurontin) are often used to control neuropathic pain. A recent double-blind, placebo-controlled study showed gabapentin to be effective in treating the pain of postherpetic neuralgia, as well as the often associated sleep disturbance.23The anticonvulsants appear to be equally effective, and drug selection often involves trial and error. Lack of response to one of these medications does not necessarily portend a poor response to another.
Topically administered lidocaine (Xylocaine) and nerve blocks have also been reported to be effective in reducing pain.OCULAR INVOLVEMENTOcular herpes zoster is treated with orally administered antiviral agents and corticosteroids, the same as involvement elsewhere.
The dosages required for analgesia are often lower than those used in the treatment of epilepsy.Anticonvulsants are associated with a variety of side effects, including sedation, memory disturbances, electrolyte abnormalities, liver toxicity and thrombocytopenia. Although most patients with ocular herpes zoster improve without lasting sequelae, some may develop severe complications, including loss of vision. Side effects may be reduced or eliminated by initiating treatment in a low dosage, which can then be slowly titrated upward.There are no specific contraindications to using anticonvulsants in combination with antidepressants or analgesics. When herpes zoster involves the eyes, ophthalmologic consultation is usually recommended.PREVENTIVE TREATMENTThe morbidity and mortality of herpes zoster could be reduced if a safe and effective preventive treatment were available. However, the risk of side effects increases when multiple medications are used.Effective treatment of postherpetic neuralgia often requires multiple treatment approaches.
It is unusual for a patient to develop herpes zoster more than once, suggesting that the first reactivation of varicella-zoster virus usually provides future immunologic protection. Was to prevent complications common complications andherpes zoster janipsilateral deafness .



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Comments
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